Provider Demographics
NPI:1154796712
Name:REYNOLDS, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:OCEAN VIEW
Mailing Address - State:DE
Mailing Address - Zip Code:19970-0357
Mailing Address - Country:US
Mailing Address - Phone:443-553-5368
Mailing Address - Fax:
Practice Address - Street 1:17 ATLANTIC AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:OCEAN VIEW
Practice Address - State:DE
Practice Address - Zip Code:19970-9102
Practice Address - Country:US
Practice Address - Phone:443-553-5368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0003786225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist